Degenerative Marrow Changes (Signal intensity changes) adjacent to the endplates of degenerated discs are a common observation on MR images. This is a teaching lecture given twice by Prof. Dr. Mohamed Mohi Eldin, professor of neurosurgery, in the weekly conference of kasr El Aini Neurosurgery Department, Cairo University, November 2010 and January 2013.

1. Spine Study Archives
MMoohhaammeedd MMoohhii EEllddiinn , MB-BCH ,
M.Sc., MD
Professor of Neurosurgery
Faculty of Medicine
Cairo University
EGYPT
Weekly Neurosurgical Conference – Kasr El Aini, 25 November 2010

2. Spine Study Archives
Vertebral Endplate
Signal Changes (VESC)
(Subchondral Marrow Modic
Changes)

3. Popularly termed as
‘EP changes’.
However,
These changes are
in the vertebral marrow
and subchondral bone
and not the EP.

4. Normal marrow
Normal hematopoetic (H),
lipid (L), and
bone trabecular (T) elements.

5. ‘Degenerative Marrow Changes’
(Signal intensity changes)
• adjacent to the endplates of degenerated
discs are a common observation on MR
images
• First noted on MRI by de Roos et al in 1987
• Modic et al. (1988) described classification
(3 types of changes)

7. Modic type 1 deg. changes (MI)
Hypointense on T1WI (A)
Hyperintense on T2WI (B)

8. Modic changes
type 1 in
lower endplate
of L4
and
upper endplate
of L5

9. Modic Type I (Edema)
Described as disruption and fissuring of the endplate
with regions of degeneration, regeneration, and
vascular granulation tissue.
Correspond to the inflammatory stage of DDD
Indicate an ongoing active degenerative process

10. Type I changes
• identified in
– 4% of scanned patients
– 19% of lumbar DDD
– 8% after discectomy
– 40%–50% of chymopapain-treated
disks, ( a model of
acute disk degeneration).
• Enhancement is seen
with contrast that at times
extends to involve the
disc itself (related to the
vascularized fibrous
tissue within the adjacent
marrow)
Histologic slide
Fibrovascular tissue (FV) has replaced normal
marrow elements between thickened bone
trabeculae (T).

11. Type 1 Modic Changes are
Unstable Dynamic Lesions
Unstable: all converted into either type 2
changes or back to normal within 6 months
following lumbar fusion, which paralleled
clinical improvement in all patients.
Dynamic: in most cases, either increase in
size or convert into type 2 changes.

12. LDP a strong risk factor for developing
MI, during the following year.
Herniation 1 year ago Present LBP

13. Always consider Modic changes if
Patients develop
NEW severe LBP within a year
after sciatica / herniation
and
Treatment does not help

14. Modic type 2 degenerative
changes (MII)
hyperintense on T1WI (A)
isointense or slightly hyperintense on T2WI (B)

15. Modic changes
type 2 in the
lower endplate
of L5
and
the upper
endplate of S1

16. Modic Type II
(Fatty change)
The normal red hematopoetic bone marrow elements are replaced by
abundant yellow fat (yellow marrow) as a result of marrow ischemia.
Represent the fatty stage of DDD
Related to a more stable and chronic process.

17. Type II changes
• Identified in
– 16% of scanned
patients
– 59% of lumbar DDD
• Discs with type II
changes also show
evidence of
endplate disruption
Increased lipid content of the marrow space (L).
Note also thickened woven bone trabeculae (T).

18. Type 2 Modic Changes may be
Less stable Lesions
• Neither as stable nor as quiescent as
originally believed
• MI & MII are interchangeable
• An acute ongoing inflammatory process in
some type 2 changes causes conversion
of yellow to red marrow,
• Suggests superimposed changes such as
continued or accelerated degeneration

19. Modic type 3 degenerative changes
(MIII)
Hypointense on both
T1WI (A) and T2WI (B)

20. Type III changes
(Lack of signal)
• Correlate with extensive
bony sclerosis on plain
radiographs.
• Reflects the relative
absence of marrow in
areas of advanced
sclerosis
• Considering the
histology;
– dense woven bone within
the vertebral body

21. Modic Type III
(Sclerosis)
are presumably bone sclerosis

22. Unlike M III,
MI & MII show
no definite correlation with sclerosis
at radiography

23. Other Types
• Mixed-type 1/2 and 2/3 Modic changes
– changes can convert from one type to another
– they all present different stages of the same
pathologic process
– develop before conversion to one of the true Modic
types
• The absence of Modic changes, a normal
anatomic appearance, has often been
designated Modic type 0.

24. Modic changes are
• uncommon in asymptomatic individuals without
DDD (4-16%)
• In DDD of the lumbar spine:
– 40% of patients with persistent LBP
– Age
– Previous disc herniation
– Heavy smoking
– Hard physical work
– Overweight
– Type 1 and 2 changes the most common
– Type 3 and mixed-type changes relatively rare.

25. Similar marrow changes have also
been noted in the pedicles
• Originally described with spondylolysis,
• They have also been noted in with
– degenerative facet disease and
– pedicle fractures.
• Probably a reflection of abnormal stresses
(loading or motion).

26. Source of pain Things to ask for Things to look for
Facet-joint
(persistent
LBP)
Dominant pain above the gluteal fold
Onset of pain is paraspinal
Relieved with lying down
Symptoms best with walking or sitting
Age >50 years
Pain not increased with coughing
Pain on extension/rotation (not specific for facet)
SI-joint Dominant pain above the gluteal fold
Pain below L5
3:5 positive tests:
Separation
Dorsal gliding/Thigh thrust
Gaenslen /Pelvic torsion
Compression (side lying)
Sacral thrust
Muscle ? Palpation reproduces familiar symptoms
Disc Dominant pain above/ below the gluteal fold
Age: 40s
Radicular leg pain
Pain increased with coughing/sneezing
Repetitive mechanical loading - centralization or
periferalization
SLR
Neurology
Ligament ? ?
Bone (Modic)
(persistent
LBP)
Dominant pain above the gluteal fold
Hard work + heavy smoking
Hard work + overweight
Recurrent LBP
Previous herniation
MRI

27. Modic changes
Differential Diagnosis
Intervertebral disk space infections
(Spondylodiscitis)
– Typically mimicking type 1 Modic changes
– Contrast enhancement may occur in both conditions
– The disc T2WI signal intensity is typically increased in discitis
– but often appears normal or hypointense on T2WI in DDD,
– Also, the vertebral endplates are eroded or destroyed in disc
space infection but usually preserved in DDD
– Finally, the presence of paraspinal or epidural inflammation
and/or collection should orient the diagnosis toward an infectious
process.
– The clinical presentation
– The laboratory tests such as ESR and CRP (very reliable
indicator of infection) being raised in up to 100% of patients

28. Modic changes and LBP
• DDD on its own a fairly quiet disorder,
• DDD with Modic changes much more
frequently associated with clinical
symptoms.
• MI is the most strongly associated with
LBP compared to type 2 & 3

29. ?Why Type 1
The reason for this may be that
1. Modic changes type 1 reflects earlier and
acute stages of inflammation,
2. Modic changes type 2 thought to be a
result of previous inflammation and more
progressive degeneration.

30. The reasons why Modic changes
may be painful are not known
• the pain may originate from damaged endplates in
patients with VESC.
– The lumbar vertebral endplate contains immunoreactive nerves,
– increased number of tumour necrosis factor (TNF)
immunoreactive nerve cells and fibres are present in endplates
that have VESC, especially in type 1 changes [111]. Therefore,
• a positive correlation between the presence and extent
of Modic changes and the amount of cartilage in the
extruded disk in patients undergoing lumbar
microdiskectomy and concluded that these changes may
result from avulsion-type disk herniation.

31. Modic Changes and Segmental
Instability
• Chronic LBP and type 1 Modic changes had more
frequent instability requiring arthrodesis than those with
type 2 changes.
• The persistence of type 1 Modic changes after fusion
suggests pseudarthrosis (nonfusion)
• Patients treated with anterior lumbar interbody fusion for
LBP, with type 1 Modic changes had much better
outcomes than those with isolated DDD and those with
type 2 changes, in whom the results were generally poor
• Fusion accelerates the course of type 1 Modic changes
probably by correcting the mechanical instability and that
these changes appear to be a good indicator of
satisfactory surgical outcome after arthrodesis

32. The causes of VESC are unknown
• Because VESC is present in several
specific LBP conditions, there may be
several causes.
• In patients with non-specific LBP,
• One theory is that disc injury leads to
increased loading and shear forces on the
endplates, which can lead to fissures of
the endplate

33. We know very little
about the treatment and
prognosis of VESC

34. Modic changes following lumbar
discectomy
• Endplate changes described following
discectomy, with varying prevalence from 6 to
18% and as a sign of septic and aseptic discitis.
• The prevalence of Modic changes was higher in
patients who had undergone surgery for lumbar
disc herniation
• In fact, type 1 changes have been shown to
develop in models of accelerated disc
degeneration :
– 8% of patients following diskectomy
– 40% following chemonucleolysis,

35. Conclusion
• Modic changes are dynamic markers of
the normal age-related degenerative
process affecting the lumbar spine.
• Finally, the exact nature and pathogenetic
significance of type 3 changes remains
largely unknown.

36. In addition to classification into different types:
the involvement of one or both endplates,
anteroposterior localization (anterior, posterior, or central),
maximal vertical depth (mm), and
extent of Modic changes
were also analyzed.
If there were Modic changes at both superior and inferior endplates, the
two vertical distances were added for a sum score (mm).
The extent of changes was estimated from sagittal or axial sequences
as quadrants of the endplate area (1-25%, 26-50%, 51-75%, or
>76%)

42. THANK YOU